
<form id='form_reg_pay' method='post' action='<?php echo site_url("user/create_account_payment/save/")?> ' onsubmit="return Send('#form_reg_pay');">
	<!-- -->
	<div class='info'>To register with KashFX, please complete the form
		below and click the "Submit" button. KashFX will contact you to
		activate your account. In order to complete the registration process,
		please also provide us with a copy of your passport or driving licence
		along with a recent utility bill or bank statement no less than three
		months old.</div>
	<div id='space'></div>
	<div id='tbls_container'>
		<div id='account_type_select'>
			<label id='accountTypeSelectorLbl' for='accountTypeSelector'>Account
				for: </label> <select id='accountTypeSelector'
				name='accountTypeSelector'>
				<option value='personal' selected='selected'>Personal Payments</option>
				<option value='business'>Business Payments</option>
			</select>
		</div>

		<div id='space'></div>

		<table cellspacing='2' cellpadding='0' align='center' width='90%'>
			<tr class='section_header'>
				<td colspan='2'>
					<div class='lbackground'></div>

					<div class='header_center'>
						<div class='rbackground'></div>
						Your details:
					</div>
				</td>
			</tr>

			<tr>
				<td width='50%'><label id='titleLbl' for='title'>Title:</label>
				</td>
				<td width='50%'><select id='title' name='title' class='userinput'>
						<option value='Mr.'>Mr.</option>
						<option value='Mrs.'>Mrs.</option>
						<option value='Ms.'>Ms.</option>
						<option value='Dr.'>Dr.</option>
						<option value='Rev.'>Rev.</option>
				</select>
				</td>
			</tr>

			<tr>
				<td><label for='fName' id='fNameLbl'>First Name:*</label>
				</td>
				<td><input name='fName' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='lName' id='lNameLbl'>Last Name:*</label>
				</td>
				<td><input name='lName' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='email' id='emailLbl'>E-mail:*</label>
				</td>
				<td><input name='email' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label id='verififyEmailLbl' for='verififyEmail'>Verify e-mail
						address:*</label>
				</td>
				<td><input name='verifyEmail' type='text' size='40'
					class='userinput'></input>
				</td>
			</tr>


			<tr>
				<td><label for='login' id='loginLbl'>Username:*</label>
				</td>
				<td><input name='login' type='text' size='40' class='userinput'></input>
				</td>
			</tr>


			<tr>
				<td><label for='passwd' id='passwdLbl'>Password:*</label>
				</td>
				<td><input name='passwd' type='password' size='40' class='userinput'></input>
				</td>
			</tr>


			<tr>
				<td><label for='passwdVerify' id='passwdVerifyLbl'>Verify Password:*</label>
				</td>
				<td><input name='passwdVerify' type='password' size='40'
					class='userinput'></input>
				</td>
			</tr>

		</table>



		<div id='space'></div>

		<table cellspacing='2' cellpadding='0' align='center' width='90%'>
			<tr class='section_header'>
				<td colspan='2'>
					<div class='lbackground'></div>

					<div class='header_center'>
						<div class='rbackground'></div>
						Further details:
					</div>
				</td>
			</tr>

			<tr>
				<td width='50%'><label id='titleLbl' for='title'>Address:*</label>
				</td>
				<td width='50%'><input name='addressLine1' type='text' size='40'
					class='userinput'></input> <br /> <input name='addressLine2'
					type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='cityMain' id='cityMainLbl'>City/Town:*</label>
				</td>
				<td><input name='cityMain' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='regionMain' id='regionMainLbl'>County/State:</label>
				</td>
				<td><input name='regionMain' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='pCodeMain' id='pCodeMainLbl'>Postal Code:</label>
				</td>
				<td><input name='pCodeMain' type='text' size='20' class='userinput'></input>
				</td>
			</tr>


			<tr>
				<td><label id='countryMainLbl' for='countryMain'>Country:*</label>
				</td>
				<td><select id='countryMain' name='countryMain' class='userinput'>
						<option value=''>Select One</option>
						<option value=''>-------------------------</option>
						<?php foreach($countries as $item){?>
						<option value='<?php print $item->ID; ?>'
							rel='<?php print $item->AREA_CODE; ?>'>
							<?php print $item->NAME; ?>
						</option>

						<?php }?>
				</select>
				</td>
			</tr>


			<tr>
				<td><label for='homePhoneMain1' id='homePhoneMain1Lbl'>Home Phone:*
				</label>
				</td>
				<td><input id='homePhoneMain1' name='homePhoneMain1' type='text'
					size='8' maxlength='6' class='userinput'></input>- <input
					id='homePhoneMain2' name='homePhoneMain2' type='text' size='8'
					maxlength='6' class='userinput'></input>- <input
					id='homePhoneMain3' name='homePhoneMain3' type='text' size='12'
					maxlength='10' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='faxMain1' id='faxMain1Lbl'>Fax: </label>
				</td>
				<td><input id='faxMain1' name='faxMain1' type='text' size='8'
					maxlength='6' class='userinput'></input>- <input id='faxMain2'
					name='faxMain2' type='text' size='8' maxlength='6'
					class='userinput'></input>- <input id='faxMain3' name='faxMain3'
					type='text' size='12' maxlength='10' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='mobilePhoneMain1' id='mobilePhoneMain1Lbl'>Mobile: </label>
				</td>
				<td><input id='mobilePhoneMain1' name='mobilePhoneMain1' type='text'
					size='8' maxlength='6' class='userinput'></input>- <input
					id='mobilePhoneMain2' name='mobilePhoneMain2' type='text' size='8'
					maxlength='6' class='userinput'></input>- <input
					id='mobilePhoneMain3' name='mobilePhoneMain3' type='text' size='12'
					maxlength='10' class='userinput'></input>
					<div class='phoneHint msg_important'>(country code + area code +
						number)</div>
				</td>
			</tr>
		</table>

		<div id='space'></div>

		<div id='business_details'>
			<table cellspacing='2' cellpadding='0' align='center' width='90%'>
				<tr class='section_header'>
					<td colspan='2'>
						<div class='lbackground'></div>

						<div class='header_center'>
							<div class='rbackground'></div>
							Business details:
						</div>
					</td>
				</tr>

				<tr>
					<td width='50%'><label id='businessNameLbl' for='businessName'>Name:*</label>
					</td>
					<td width='50%'><input name='businessName' type='text' size='40'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label id='titleLbl' for='title'>Address:*</label>
					</td>
					<td><input name='addressLine1Business' type='text' size='40'
						class='userinput'></input> <br /> <input
						name='addressLine2Business' type='text' size='40'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label id='countryBusinessLbl' for='countryBusiness'>Registration
							Country:*</label>
					</td>
					<td><select id='countryBusiness' name='countryBusiness'
						class='userinput'>
							<option value=''>Select One</option>
							<option value=''>-------------------------</option>
							<?php foreach($countries as $item){?>
							<option value='<?php print $item->ID; ?>'
								rel='<?php print $item->AREA_CODE; ?>'>
								<?php print $item->NAME; ?>
							</option>

							<?php }?>
					</select>
					</td>
				</tr>

				<tr>
					<td><label for='emailBusiness' id='emailBusinessLbl'>E-mail:*</label>
					</td>
					<td><input name='emailBusiness' type='text' size='40'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='businessPhone1' id='businessPhoneLbl'>Phone:* </label>
					</td>
					<td><input id='businessPhone1' name='businessPhone1' type='text'
						size='8' maxlength='6' class='userinput'></input>- <input
						id='businessPhone2' name='businessPhone2' type='text' size='8'
						maxlength='6' class='userinput'></input>- <input
						id='businessPhone3' name='businessPhone3' type='text' size='12'
						maxlength='10' class='userinput'></input>
						<div class='phoneHint msg_important'>(country code + area code +
							number)</div>
					</td>
				</tr>

				<tr>
					<td><label for='regNumber' id='regNumberLbl'>Registration number:*</label>
					</td>
					<td><input name='regNumber' type='text' size='30' class='userinput'></input>
					</td>
				</tr>


				<tr>
					<td><label for='businessType' id='businessTypeLbl'>Business Type:*</label>
					</td>
					<td><input name='businessType' type='text' size='30'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='revenue' id='revenueLbl'>Anual revenue ($):*</label>
					</td>
					<td><input name='revenue' type='text' size='30' class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='transactionsNr' id='transactionsNrLbl'>No Of
							transactions per week:*</label>
					</td>
					<td><input name='transactionsNr' type='text' size='30'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='avgTransactionSize' id='avgTransactionSizeLbl'>Average
							size of each transaction ($):*</label>
					</td>
					<td><input name='avgTransactionSize' type='text' size='30'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label id='currencyTradedLbl' for='currencyTraded'>Major
							Currencies Traded:*</label>
					</td>
					<td><select id='currencyTraded' name='currencyTraded[]' size='6'
						multiple='multiple' class='userinput'>
							<option value='GBP'>GBP</option>
							<option value='USD'>USD</option>
							<option value='EUR'>EUR</option>
							<option value='JPY'>JPY</option>
							<option value='AUD'>AUD</option>
							<option value='CAD'>CAD</option>
					</select> <span class='msg_important'> (hold &lt;Ctrl&gt; to select
							multiple) </span>
					</td>
				</tr>

				<tr>
					<td><label for='businessRegDay' id='businessRegDateLbl'>Business
							Registration Date:*</label>
					</td>
					<td><select id='businessRegDay' name='businessRegDay'
						class='userinput'>
							<option value=''>DD</option>
							<?php for($day = 1; $day <= 31; $day++){?>
							<option value='<?php print $day; ?>'>
							<?php print $day; ?>
							</option>
							<?php }?>
					</select> / <select id='businessRegMonth' name='businessRegMonth'
						class='userinput'>
							<option value=''>MM</option>
							<?php for($mon = 1; $mon <= 12; $mon++){?>
							<option value='<?php print $mon; ?>'>
							<?php print $mon; ?>
							</option>
							<?php }?>
					</select> / <select id='businessRegYear' name='businessRegYear'
						class='userinput'>
							<option value=''>YYYY</option>
							<?php for($y = 1980; $y <= 2010; $y++){?>
							<option value='<?php print $y; ?>'>
							<?php print $y; ?>
							</option>
							<?php }?>
					</select> (DD/MM/YYYY)</td>
				</tr>

				<tr>
					<td><label for='businessOwner' id='businessOwnerLbl'>Business
							Owner:*</label>
					</td>
					<td><input name='businessOwner' type='text' size='45'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='businessNature' id='businessNatureLbl'>Nature of
							Business:</label>
					</td>
					<td><input name='businessNature' type='text' size='45'
						class='userinput'></input>
					</td>
				</tr>

				<tr>
					<td><label for='contactPerson' id='contactPersonLbl'>Contact
							Person:*</label>
					</td>
					<td><input name='contactPerson' type='text' size='45'
						class='userinput'></input>
					</td>
				</tr>
			</table>
		</div>

		<table cellspacing='2' cellpadding='0' align='center' width='90%'>
			<tr class='section_header'>
				<td colspan='2'>
					<div class='lbackground'></div>

					<div class='header_center'>
						<div class='rbackground'></div>
						Currency Requirements:
					</div>
				</td>
			</tr>

			<tr>
				<td width='50%'><label id='kashfxdealerLbl' for='kashfxdealer'>Have you spoken
						with someone at KashFX?</label>
				</td>
				<td width='50%'><select name="kashfxdealer" id="kashfxdealer"
					class='userinput'>
						<option value="No" selected>(Select one)</option>
						<option value="No">No</option>
						<?php foreach($dealers as $item){?>
						<option value='<?php print $item->ID; ?>'>
						<?php print $item->NUME; ?>
						</option>
						<?php }?>
				</select>
				</td>
			</tr>
			<tr>
				<td><label id='availableCurrencyLbl' for='availableCurrency'>Which
						currency do you have?*</label>
				</td>
				<td><select name="availableCurrency" id='availableCurrency'
					class='userinput'>
						<option value="">-- Currency --</option>
						<option value="EUR" selected>Euro...EUR</option>
						<option value="USD">US Dollar...USD</option>

						<option value="GBP">British Pound...GBP</option>
						<option value="AFA">Afghanistan Afghani...AFA</option>
						<option value="ALL">Albanian Lek...ALL</option>
						<option value="DZD">Algerian Dinar...DZD</option>
						<option value="ADF">Andorran Franc...ADF</option>
						<option value="ADP">Andorran Peseta...ADP</option>

						<option value="AON">Angolan New Kwanza...AON</option>
						<option value="ARS">Argentine Peso...ARS</option>
						<option value="AWG">Aruban Florin...AWG</option>
						<option value="AUD">Australian Dollar...AUD</option>
						<option value="EUR">Austrian...EUR</option>
						<option value="BSD">Bahamanian Dollar...BSD</option>

						<option value="BHD">Bahraini Dinar...BHD</option>
						<option value="BDT">Bangladeshi Taka...BDT</option>
						<option value="BBD">Barbados Dollar...BBD</option>
						<option value="EUR">Belgian...EURO</option>
						<option value="BZD">Belize Dollar...BZD</option>
						<option value="BMD">Bermudian Dollar...BMD</option>

						<option value="BTN">Bhutan Ngultrum...BTN</option>
						<option value="BOB">Bolivian Boliviano...BOB</option>
						<option value="BWP">Botswana Pula...BWP</option>
						<option value="BRL">Brazilian Real...BRL</option>
						<option value="BND">Brunei Dollar...BND</option>
						<option value="BGL">Bulgarian Lev...BGL</option>

						<option value="BIF">Burundi Franc...BIF</option>
						<option value="XOF">CFA Franc BCEAO...XOF</option>
						<option value="XAF">CFA Franc BEAC...XAF</option>
						<option value="KHR">Cambodian Riel...KHR</option>
						<option value="CAD">Canadian Dollar...CAD</option>
						<option value="CVE">Cape Verde Escudo...CVE</option>

						<option value="KYD">Cayman Islands Dollar...KYD</option>
						<option value="CFP">Central Pacific Franc...CFP</option>
						<option value="CLP">Chilean Peso...CLP</option>
						<option value="CNY">Chinese Yuan Renminbi...CNY</option>
						<option value="COP">Colombian Peso...COP</option>
						<option value="KMF">Comoros Franc...KMF</option>

						<option value="CRC">Costa Rican Colon...CRC</option>
						<option value="HRK">Croatian Kuna...HRK</option>
						<option value="CUP">Cuban Peso...CUP</option>
						<option value="CYP">Cyprus Pound...CYP</option>
						<option value="CSK">Czech Koruna...CSK</option>
						<option value="DKK">Danish Krone...DKK</option>

						<option value="DJF">Djibouti Franc...DJF</option>
						<option value="DOP">Dominican R. Peso...DOP</option>
						<option value="NLG">Dutch Guilder...NLG</option>
						<option value="XEU">ECU...XEU</option>
						<option value="XCD">East Caribbean Dollar...XCD</option>
						<option value="ECS">Ecuador Sucre...ECS</option>

						<option value="EGP">Egyptian Pound...EGP</option>
						<option value="SVC">El Salvador Colon...SVC</option>
						<option value="EEK">Estonian Kroon...EEK</option>
						<option value="ETB">Ethiopian Birr...ETB</option>
						<option value="FKP">Falkland Islands Pound...FKP</option>
						<option value="FJD">Fiji Dollar...FJD</option>

						<option value="EUR">Finnish ...EUR</option>
						<option value="EUR">French ...EUR</option>
						<option value="GMD">Gambian Dalasi ...GMD</option>
						<option value="EUR">German ...EUR</option>
						<option value="GHC">Ghanaian Cedi...GHC</option>
						<option value="GIP">Gibraltar Pound...GIP</option>

						<option value="XAU">Gold (oz.)...XAU</option>
						<option value="GRD">Greek Drachma...GRD</option>
						<option value="GTQ">Guatemalan Quetzal...GTQ</option>
						<option value="GNF">Guinea Franc...GNF</option>
						<option value="GYD">Guyanese Dollar...GYD</option>
						<option value="HTG">Haitian Gourde...HTG</option>

						<option value="HNL">Honduran Lempira...HNL</option>
						<option value="HKD">Hong Kong Dollar...HKD</option>
						<option value="HUF">Hungarian Forint...HUF</option>
						<option value="ISK">Iceland Krona...ISK</option>
						<option value="INR">Indian Rupee...INR</option>
						<option value="IDR">Indonesian Rupiah...IDR</option>

						<option value="IRR">Iranian Rial...IRR</option>
						<option value="IQD">Iraqi Dinar...IQD</option>
						<option value="EUR">Irish ...EUR</option>
						<option value="ILS">Israeli New Shekel...ILS</option>
						<option value="EUR">Italian ...EURO</option>
						<option value="JMD">Jamaican Dollar...JMD</option>

						<option value="JPY">Japanese Yen...JPY</option>
						<option value="JOD">Jordanian Dinar...JOD</option>
						<option value="KZT">Kazakhstan Tenge...KZT</option>
						<option value="KES">Kenyan Shilling...KES</option>
						<option value="KWD">Kuwaiti Dinar...KWD</option>
						<option value="LAK">Lao Kip...LAK</option>

						<option value="LVL">Latvian Lats...LVL</option>
						<option value="LBP">Lebanese Pound...LBP</option>
						<option value="LSL">Lesotho Loti...LSL</option>
						<option value="LRD">Liberian Dollar...LRD</option>
						<option value="LYD">Libyan Dinar...LYD</option>
						<option value="LTL">Lithuanian Litas...LTL</option>

						<option value="EUR">Luxembourg...EURO</option>
						<option value="MOP">Macau Pataca...MOP</option>
						<option value="MGF">Malagasy Franc...MGF</option>
						<option value="MWK">Malawi Kwacha...MWK</option>
						<option value="MYR">Malaysian Ringgit...MYR</option>
						<option value="MVR">Maldive Rufiyaa...MVR</option>

						<option value="MTL">Maltese Lira...MTL</option>
						<option value="MRO">Mauritanian Ouguiya...MRO</option>
						<option value="MUR">Mauritius Rupee...MUR</option>
						<option value="MXP">Mexican Peso...MXP</option>
						<option value="MNT">Mongolian Tugrik...MNT</option>
						<option value="MAD">Moroccan Dirham...MAD</option>

						<option value="MZM">Mozambique Metical...MZM</option>
						<option value="MMK">Myanmar Kyat...MMK</option>
						<option value="ANG">NL Antillian Guilder...ANG</option>
						<option value="NAD">Namibia Dollar...NAD</option>
						<option value="NPR">Nepalese Rupee...NPR</option>
						<option value="EUR">Netherlands...EURO</option>

						<option value="NZD">New Zealand Dollar...NZD</option>
						<option value="NIO">Nicaraguan Cordoba Oro...NIO</option>
						<option value="NGN">Nigerian Naira...NGN</option>
						<option value="KPW">North Korean Won...KPW</option>
						<option value="NOK">Norwegian Kroner...NOK</option>
						<option value="OMR">Omani Rial...OMR</option>

						<option value="PKR">Pakistan Rupee...PKR</option>
						<option value="XPD">Palladium (oz.)...XPD</option>
						<option value="PAB">Panamanian Balboa...PAB</option>
						<option value="PGK">Papua New Guinea Kina...PGK</option>
						<option value="PYG">Paraguay Guarani...PYG</option>
						<option value="PEN">Peruvian Nuevo Sol...PEN</option>

						<option value="PHP">Philippine Peso...PHP</option>
						<option value="XPT">Platinum (oz.)...XPT</option>
						<option value="PLZ">Polish Zloty...PLZ</option>
						<option value="EUR">Portuguese...EURO</option>
						<option value="QAR">Qatari Rial...QAR</option>
						<option value="ROL">Romanian Leu...ROL</option>

						<option value="RUB">Russian Rouble...RUB</option>
						<option value="WST">Samoan Tala...WST</option>
						<option value="STD">Sao Tome/Principe Dobra...STD</option>
						<option value="SAR">Saudi Riyal...SAR</option>
						<option value="SCR">Seychelles Rupee...SCR</option>
						<option value="SLL">Sierra Leone Leone...SLL</option>

						<option value="XAG">Silver (oz.)...XAG</option>
						<option value="SGD">Singapore Dollar...SGD</option>
						<option value="SKK">Slovak Koruna...SKK</option>
						<option value="SIT">Slovenian Tolar...SIT</option>
						<option value="SBD">Solomon Islands Dollar...SBD</option>
						<option value="SOS">Somali Shilling...SOS</option>

						<option value="ZAR">South African Rand...ZAR</option>
						<option value="KRW">South-Korean Won...KRW</option>
						<option value="EUR">Spanish ...EURO</option>
						<option value="LKR">Sri Lanka Rupee...LKR</option>
						<option value="SHP">St. Helena Pound...SHP</option>
						<option value="SDD">Sudanese Dinar...SDD</option>

						<option value="SDP">Sudanese Pound...SDP</option>
						<option value="SRG">Suriname Guilder...SRG</option>
						<option value="SZL">Swaziland Lilangeni...SZL</option>
						<option value="SEK">Swedish Krona...SEK</option>
						<option value="CHF">Swiss Franc...CHF</option>
						<option value="SYP">Syrian Pound...SYP</option>

						<option value="TWD">Taiwan Dollar...TWD</option>
						<option value="TZS">Tanzanian Shilling...TZS</option>
						<option value="THB">Thai Baht...THB</option>
						<option value="TOP">Tonga Pa'anga...TOP</option>
						<option value="TTD">Trinidad/Tobago Dollar...TTD</option>
						<option value="TND">Tunisian Dinar...TND</option>

						<option value="TRL">Turkish Lira...TRL</option>
						<option value="UGS">Uganda Shilling...UGS</option>
						<option value="UAH">Ukraine Hryvnia...UAH</option>
						<option value="UYP">Uruguayan Peso...UYP</option>
						<option value="AED">Utd. Arab Emir. Dirham...AED</option>
						<option value="VUV">Vanuatu Vatu...VUV</option>

						<option value="VEB">Venezuelan Bolivar...VEB</option>
						<option value="VND">Vietnamese Dong...VND</option>
						<option value="YUN">Yugoslav Dinar...YUN</option>
						<option value="ZMK">Zambian Kwacha...ZMK</option>
						<option value="ZWD">Zimbabwe Dollar...ZWD</option>
				</select>
				</td>
			
			
			<tr>
			
			
			<tr>
				<td><label id='requiredCurrencyLbl' for='requiredCurrency'>Which
						currency do you require?*</label>
				</td>
				<td><select name="requiredCurrency" class='userinput'>
						<option value="">-- Currency --</option>
						<option value="EUR" selected>Euro...EUR</option>
						<option value="USD">US Dollar...USD</option>

						<option value="GBP">British Pound...GBP</option>
						<option value="AFA">Afghanistan Afghani...AFA</option>
						<option value="ALL">Albanian Lek...ALL</option>
						<option value="DZD">Algerian Dinar...DZD</option>
						<option value="ADF">Andorran Franc...ADF</option>
						<option value="ADP">Andorran Peseta...ADP</option>

						<option value="AON">Angolan New Kwanza...AON</option>
						<option value="ARS">Argentine Peso...ARS</option>
						<option value="AWG">Aruban Florin...AWG</option>
						<option value="AUD">Australian Dollar...AUD</option>
						<option value="EUR">Austrian...EUR</option>
						<option value="BSD">Bahamanian Dollar...BSD</option>

						<option value="BHD">Bahraini Dinar...BHD</option>
						<option value="BDT">Bangladeshi Taka...BDT</option>
						<option value="BBD">Barbados Dollar...BBD</option>
						<option value="EUR">Belgian...EURO</option>
						<option value="BZD">Belize Dollar...BZD</option>
						<option value="BMD">Bermudian Dollar...BMD</option>

						<option value="BTN">Bhutan Ngultrum...BTN</option>
						<option value="BOB">Bolivian Boliviano...BOB</option>
						<option value="BWP">Botswana Pula...BWP</option>
						<option value="BRL">Brazilian Real...BRL</option>
						<option value="BND">Brunei Dollar...BND</option>
						<option value="BGL">Bulgarian Lev...BGL</option>

						<option value="BIF">Burundi Franc...BIF</option>
						<option value="XOF">CFA Franc BCEAO...XOF</option>
						<option value="XAF">CFA Franc BEAC...XAF</option>
						<option value="KHR">Cambodian Riel...KHR</option>
						<option value="CAD">Canadian Dollar...CAD</option>
						<option value="CVE">Cape Verde Escudo...CVE</option>

						<option value="KYD">Cayman Islands Dollar...KYD</option>
						<option value="CFP">Central Pacific Franc...CFP</option>
						<option value="CLP">Chilean Peso...CLP</option>
						<option value="CNY">Chinese Yuan Renminbi...CNY</option>
						<option value="COP">Colombian Peso...COP</option>
						<option value="KMF">Comoros Franc...KMF</option>

						<option value="CRC">Costa Rican Colon...CRC</option>
						<option value="HRK">Croatian Kuna...HRK</option>
						<option value="CUP">Cuban Peso...CUP</option>
						<option value="CYP">Cyprus Pound...CYP</option>
						<option value="CSK">Czech Koruna...CSK</option>
						<option value="DKK">Danish Krone...DKK</option>

						<option value="DJF">Djibouti Franc...DJF</option>
						<option value="DOP">Dominican R. Peso...DOP</option>
						<option value="NLG">Dutch Guilder...NLG</option>
						<option value="XEU">ECU...XEU</option>
						<option value="XCD">East Caribbean Dollar...XCD</option>
						<option value="ECS">Ecuador Sucre...ECS</option>

						<option value="EGP">Egyptian Pound...EGP</option>
						<option value="SVC">El Salvador Colon...SVC</option>
						<option value="EEK">Estonian Kroon...EEK</option>
						<option value="ETB">Ethiopian Birr...ETB</option>
						<option value="FKP">Falkland Islands Pound...FKP</option>
						<option value="FJD">Fiji Dollar...FJD</option>

						<option value="EUR">Finnish ...EUR</option>
						<option value="EUR">French ...EUR</option>
						<option value="GMD">Gambian Dalasi ...GMD</option>
						<option value="EUR">German ...EUR</option>
						<option value="GHC">Ghanaian Cedi...GHC</option>
						<option value="GIP">Gibraltar Pound...GIP</option>

						<option value="XAU">Gold (oz.)...XAU</option>
						<option value="GRD">Greek Drachma...GRD</option>
						<option value="GTQ">Guatemalan Quetzal...GTQ</option>
						<option value="GNF">Guinea Franc...GNF</option>
						<option value="GYD">Guyanese Dollar...GYD</option>
						<option value="HTG">Haitian Gourde...HTG</option>

						<option value="HNL">Honduran Lempira...HNL</option>
						<option value="HKD">Hong Kong Dollar...HKD</option>
						<option value="HUF">Hungarian Forint...HUF</option>
						<option value="ISK">Iceland Krona...ISK</option>
						<option value="INR">Indian Rupee...INR</option>
						<option value="IDR">Indonesian Rupiah...IDR</option>

						<option value="IRR">Iranian Rial...IRR</option>
						<option value="IQD">Iraqi Dinar...IQD</option>
						<option value="EUR">Irish ...EUR</option>
						<option value="ILS">Israeli New Shekel...ILS</option>
						<option value="EUR">Italian ...EURO</option>
						<option value="JMD">Jamaican Dollar...JMD</option>

						<option value="JPY">Japanese Yen...JPY</option>
						<option value="JOD">Jordanian Dinar...JOD</option>
						<option value="KZT">Kazakhstan Tenge...KZT</option>
						<option value="KES">Kenyan Shilling...KES</option>
						<option value="KWD">Kuwaiti Dinar...KWD</option>
						<option value="LAK">Lao Kip...LAK</option>

						<option value="LVL">Latvian Lats...LVL</option>
						<option value="LBP">Lebanese Pound...LBP</option>
						<option value="LSL">Lesotho Loti...LSL</option>
						<option value="LRD">Liberian Dollar...LRD</option>
						<option value="LYD">Libyan Dinar...LYD</option>
						<option value="LTL">Lithuanian Litas...LTL</option>

						<option value="EUR">Luxembourg...EURO</option>
						<option value="MOP">Macau Pataca...MOP</option>
						<option value="MGF">Malagasy Franc...MGF</option>
						<option value="MWK">Malawi Kwacha...MWK</option>
						<option value="MYR">Malaysian Ringgit...MYR</option>
						<option value="MVR">Maldive Rufiyaa...MVR</option>

						<option value="MTL">Maltese Lira...MTL</option>
						<option value="MRO">Mauritanian Ouguiya...MRO</option>
						<option value="MUR">Mauritius Rupee...MUR</option>
						<option value="MXP">Mexican Peso...MXP</option>
						<option value="MNT">Mongolian Tugrik...MNT</option>
						<option value="MAD">Moroccan Dirham...MAD</option>

						<option value="MZM">Mozambique Metical...MZM</option>
						<option value="MMK">Myanmar Kyat...MMK</option>
						<option value="ANG">NL Antillian Guilder...ANG</option>
						<option value="NAD">Namibia Dollar...NAD</option>
						<option value="NPR">Nepalese Rupee...NPR</option>
						<option value="EUR">Netherlands...EURO</option>

						<option value="NZD">New Zealand Dollar...NZD</option>
						<option value="NIO">Nicaraguan Cordoba Oro...NIO</option>
						<option value="NGN">Nigerian Naira...NGN</option>
						<option value="KPW">North Korean Won...KPW</option>
						<option value="NOK">Norwegian Kroner...NOK</option>
						<option value="OMR">Omani Rial...OMR</option>

						<option value="PKR">Pakistan Rupee...PKR</option>
						<option value="XPD">Palladium (oz.)...XPD</option>
						<option value="PAB">Panamanian Balboa...PAB</option>
						<option value="PGK">Papua New Guinea Kina...PGK</option>
						<option value="PYG">Paraguay Guarani...PYG</option>
						<option value="PEN">Peruvian Nuevo Sol...PEN</option>

						<option value="PHP">Philippine Peso...PHP</option>
						<option value="XPT">Platinum (oz.)...XPT</option>
						<option value="PLZ">Polish Zloty...PLZ</option>
						<option value="EUR">Portuguese...EURO</option>
						<option value="QAR">Qatari Rial...QAR</option>
						<option value="ROL">Romanian Leu...ROL</option>

						<option value="RUB">Russian Rouble...RUB</option>
						<option value="WST">Samoan Tala...WST</option>
						<option value="STD">Sao Tome/Principe Dobra...STD</option>
						<option value="SAR">Saudi Riyal...SAR</option>
						<option value="SCR">Seychelles Rupee...SCR</option>
						<option value="SLL">Sierra Leone Leone...SLL</option>

						<option value="XAG">Silver (oz.)...XAG</option>
						<option value="SGD">Singapore Dollar...SGD</option>
						<option value="SKK">Slovak Koruna...SKK</option>
						<option value="SIT">Slovenian Tolar...SIT</option>
						<option value="SBD">Solomon Islands Dollar...SBD</option>
						<option value="SOS">Somali Shilling...SOS</option>

						<option value="ZAR">South African Rand...ZAR</option>
						<option value="KRW">South-Korean Won...KRW</option>
						<option value="EUR">Spanish ...EURO</option>
						<option value="LKR">Sri Lanka Rupee...LKR</option>
						<option value="SHP">St. Helena Pound...SHP</option>
						<option value="SDD">Sudanese Dinar...SDD</option>

						<option value="SDP">Sudanese Pound...SDP</option>
						<option value="SRG">Suriname Guilder...SRG</option>
						<option value="SZL">Swaziland Lilangeni...SZL</option>
						<option value="SEK">Swedish Krona...SEK</option>
						<option value="CHF">Swiss Franc...CHF</option>
						<option value="SYP">Syrian Pound...SYP</option>

						<option value="TWD">Taiwan Dollar...TWD</option>
						<option value="TZS">Tanzanian Shilling...TZS</option>
						<option value="THB">Thai Baht...THB</option>
						<option value="TOP">Tonga Pa'anga...TOP</option>
						<option value="TTD">Trinidad/Tobago Dollar...TTD</option>
						<option value="TND">Tunisian Dinar...TND</option>

						<option value="TRL">Turkish Lira...TRL</option>
						<option value="UGS">Uganda Shilling...UGS</option>
						<option value="UAH">Ukraine Hryvnia...UAH</option>
						<option value="UYP">Uruguayan Peso...UYP</option>
						<option value="AED">Utd. Arab Emir. Dirham...AED</option>
						<option value="VUV">Vanuatu Vatu...VUV</option>

						<option value="VEB">Venezuelan Bolivar...VEB</option>
						<option value="VND">Vietnamese Dong...VND</option>
						<option value="YUN">Yugoslav Dinar...YUN</option>
						<option value="ZMK">Zambian Kwacha...ZMK</option>
						<option value="ZWD">Zimbabwe Dollar...ZWD</option>
				</select>
				</td>
			</tr>

			<tr>
				<td><label for='transferAmount' id='transferAmountLbl'>Amount to be
						transferred:*</label>
				</td>
				<td><input name='transferAmount' type='text' size='30'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td colspan='2'><label id='currencyReqLbl'>What are your currency
						requirements?</label>
				</td>
			</tr>

			<tr>
				<td><label for='isPropertyTrans' id='isPropertyTransLbl'>Property
						transaction:</label>
				</td>
				<td><input name='isPropertyTrans' type='checkbox' value='1'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='isBusinessTrans' id='isBusinessTransLbl'>Business
						Currency Transaction:</label>
				</td>
				<td><input name='isBusinessTrans' type='checkbox' value='1'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='isRegularPayment' id='isBusinessTransLbl'>Regular
						Payments Overseas:</label>
				</td>
				<td><input name='isBusinessTrans' type='checkbox' value='1'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='isPrepaidCard' id='isPrepaidCardLbl'>Prepaid FX
						Card:</label>
				</td>
				<td><input name='isPrepaidCard' type='checkbox' value='1'
					class='userinput'></input>
				</td>
			</tr>
		</table>

		<div id='space'></div>

		<table cellspacing='2' cellpadding='0' align='center' width='90%'>
			<tr class='section_header'>
				<td colspan='2'>
					<div class='lbackground'></div>

					<div class='header_center'>
						<div class='rbackground'></div>
						Further Information:
					</div>
				</td>
			</tr>
			<tr>
				<td colspan='2'>
					<div class='info'>Some of the following questions require sensitive
						information, KahFX.com will not misuse this information but
						require it for security reasons:</div>
				</td>
			</tr>


			<tr>
				<td width='50%'><label id='refererLbl' for='referer'>Where did you
						hear about us:</label>
				</td>
				<td width='50%'><input name='referer' type='text' size='40'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label id='motherMNameLbl' for='motherMName'>Please give your
						mothers maiden name:*</label>
				</td>
				<td><input name='motherMName' type='text' size='40'
					class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label id='birthPlaceLbl' for='birthPlace'>Please give your
						place of birth:*</label>
				</td>
				<td><input name='birthPlace' type='text' size='40' class='userinput'></input>
				</td>
			</tr>


			<tr>
				<td><label id='passNumberLbl' for='passNumber'>Please give your
						passport number:*</label>
				</td>
				<td><input name='passNumber' type='text' size='40' class='userinput'></input>
				</td>
			</tr>

			<tr>
				<td><label for='birthDay' id='birthDateLbl'>Please give your date of
						birth:*</label>
				</td>
				<td><select id='birthDay' name='birthDay' class='userinput'>
						<option value=''>DD</option>
						<?php for($day = 1; $day <= 31; $day++){?>
						<option value='<?php print $day; ?>'>
						<?php print $day; ?>
						</option>
						<?php }?>
				</select> / <select id='birthMonth' name='birthMonth'
					class='userinput'>
						<option value=''>MM</option>
						<?php for($mon = 1; $mon <= 12; $mon++){?>
						<option value='<?php print $mon; ?>'>
						<?php print $mon; ?>
						</option>
						<?php }?>
				</select> / <select id='birthYear' name='birthYear'
					class='userinput'>
						<option value=''>YYYY</option>
						<?php for($y = 1980; $y <= 2010; $y++){?>
						<option value='<?php print $y; ?>'>
						<?php print $y; ?>
						</option>
						<?php }?>
				</select> (DD/MM/YYYY)</td>
			</tr>

		</table>


		<table cellspacing='2' cellpadding='0' align='center' width='90%'>
			<tr class='section_header'>
				<td colspan='2'>
					<div class='lbackground'></div>

					<div class='header_center'>
						<div class='rbackground'></div>
						Comments:
					</div>
				</td>
			</tr>

			<tr>
				<td colspan='2'><label id='additionalInfo'>Please provide any
						additional information below:</label>
				</td>
			</tr>

			<tr>
				<td>
					<p align='center'>
						<textarea name='comments' id='comments' cols='60' rows='5'
							wrap='physical' class='userinput'>
				 </textarea>
					</p>
					<p align='center'>
						<input name='accept' type='checkbox' value='1'></input> <label
							id='acceptLbl' for='accept'>I accept the <?php echo anchor(site_url('create_account_payment/terms'), 'Terms of Service', array('title' => 'Read Our Terms of Service', 'class' => 'link', 'target' => '_blank'));?>
						</label>

					</p>
				</td>
			</tr>



		</table>



		<div id='submit_section' style='text-align: center;'>
			<input type='submit' value='submit' title='Submit the form ' />
		</div>
	</div>

</form>
